9809-024 (SFD)LICENSED CONTRACTOR DECLARATION
-1 hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Protessionals Uode, and my License is In full force and effect
License # Lic. Class Exp. bate
��
740745 T3
'> a�f3i3l99
`Date q/0 Signature of Contractor ► `�!}wt
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sole.
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business &'Professionals
Code).
() I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following/ declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation,: as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
(� I have and will 'maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Cartier Policy No.
CIGNA t W[3534
o
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) (.certify that in the performance of the work for which this permit is issued,
1'shall not employ any person in any manner so as to become subject to the
workers' compensation laws of California, and agree that if I should become
subjecilo the workers'. compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
ate`., Applicant
iy-
4.
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall.subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees:
IMPORTANT Application is hereby made to the Director of Building and Safety
for a,permit subject to the conditions and restrictions .sets forth on his
application.
1. Each person upon whose behalf this application is made & each person at!
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
const.ruction.,,and hereby authorize representatives of this City to enter upon,
the above-mentioned property for inspection purposes.
ySignature (Owner/Agent) �n.9�_ Date
7
BUILDING PERMIT PERM' 91 t,24 CONTROL#
19
DATE Y VALUATION `d'? � Z � 6 LOT 2.4 TRACT ��c ,
Sift
ADDRESS ,79-970 d'Al"�'� �:LO
APNOB
OWNER " '
CONTRACTOR/DESIGNER/ENGINEER
€1P.iTAi, I)A"-1tFfC .HOI.D.TaN'CTS, WC
CAPITAL AL PACIFIC CTCfMES INC
4100 NWARTHUR Tai VI) 4200
4100 UAC. 13LVD 000
NEWPORT 6EACH CA, 92660
NEWPORT 13FAC1-1 CA 92660
(949Y22-.840 ? CBMI. 159.3
USE OF PERMIT
S IML E FAMi ,Y l )WT-,T.LLNCi
!'U - PLAN lAk LO1'#b23, PERIN11T DOES NOT INCLLME BLOCK WALL
OR, P(XA- PLAN CHECK FEE R:tMCED .BY 7.W6 k0R, MI U1T:.1'IPLss ! SSUAN-c
OF SAME. PLAN TYPE
CUSTOM CONSTARUC1.110N 1,0,59.00 ;
P0RCWPATJ,,0 'r 328.00 ST*
0ARM-11 )CARfN;3lt C 565.00 SF
S T �.l�i�A.�1 ED CONT, OF CONST �i�JCs�1011
ESTI
654,51 11.,50
` hhq y�r�gg
•�yy}} pp.�gggg��x�gg glow. SUMMARY
4".;tjr!.fSTRUJC'i'!C)N FEE 101-000-418-000 51,1�.J0
PLAN 0—CK—RE 101-000-430-3119 SIMS'"
1r€CC.t MNIC'.AL Isis s 101-000-421-•000 $981.50
_
1%f:E:E"d' U Al VIM, 1.0.1<000-420-000 S176=
PLUNMWIGFEE 103-000419 tD �dfi€3,5t)
STL> 101 (){V -^A1 -00(J 57.45
cuwxrTo .FIW 101-000-42:3-000
I'Nr-RA5`iu,uc i uAi i hE 225 -.CO -443-342 95.628 3S
A.ffl• INIaV.W1 IC.Pr,ACLS-'l &SID 01 -00t? -255+-000 33IItii,?�3
gga
tI •
.
SUI�3-TOTAT, CONST RUCT.'TON .A.ND PJ_.AN CHECK
PAIV USS PRF-1?AID FEES
X7,934„t9
$0,00
SEP 29 1998 •f0TAL ftniff FFFu%a01J C NOW
$7,9:429
TY
RECEIPT
DATE Bye
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
-MECHANICAL APPROVALS
Set BacksZ Z , ��
Forms & Footings [
Underground Ducts
Ducts
Slab Grade A LO—cj
Steel
Return Air
Combustion Air
_
Roof Deck
Exhaust Fans
O.K. to Wrap_�
Framing
Insulation_G1 _ L�
Fireplace P.L.
F.A.U.t
Compressor
Vents
Grills
C
��_
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
_
Exterior Lath G
Drywall - Int. Lath -
Final
Final _ cc/
POOLS - SPAS
BLOCKWALL APPROVALS
steel
.Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Wastelines / L -G- g r(j
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
_
Sewer Connection
Encapsulation
Gas Piping
Gas Test _L
Appliances
Final
COMMENTS:
-
Final j
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G. F.I.
Smoke Detectors
Temp. Use of Power
t
Final
Utility Notice (Perm) _00_�
Notice:
Document Cannot Be Duplicated
Desert Sands Unified School District
47-950 Dune Palms Road
La Quinta, CA 92253
760-771-8515
CERTIFICATE OF COMPLIANCE
Date 9/17/98 t APN # 769-560-023
No. '•17757 Jurisdiction La Quinta
Owner NameCapital,Pacific Holdings, Inc.
No. ,79-970 Street Tangelo
City La Quinta zip 92253
Tract # 24890-3 Lot # 23 f Square Footage
Type of Development Single Family Residence
Comments
Under grandfather agreement - 3,069 sq. ft. -(The Citrus Course)
Permit #
Log #
Study Area
1 f
No. of Units �1
At the present time, the Desert Sands Unified. School District does not collect fees on garages/carports,. covered
patios/walkways, residential additions under 500 square feet, detached accessory structures or replacement mobilehomes.
It has been determined the above-named owner is exempt .from paying school fees at this time due to the following
reason: t
Under Mitigation Agreement
EXEMPTION NOT APPLICABLE
This certifies that school,facility fees imposed pursuant to Mitigation Agreement in the amount of
628.00 X 1 or $ 628.00 the property listed above and that building r
permits and/or Certificates of Occupancy for this square footage in this proposed project mavnow be issued
Fees Paid By CC/Wells Fargo & Co./Manuel Telephone-564,4475rQ
Name on the check
By Dr. Doris Wilson
Superintendent
Fee collected /exempted by Juanita Green Payment Received $628.00
a
Check No. 0643036924
Signature
NOTICE: Pursuant of Assably Bill 3081 (CHAP 549, STATS. 1996) this will serve to notify you that the 90 -day approval period in which you may protest the fees or other payment identified
above will begin to run from the date on which the building or installation permit for this project is sssued or on which they are paid to the District(s) or to another public entity authorized to
collect them on the Dislrict('s)(s') behalf, whichever is earlier.
C� Collector: Attach a copy of county or city plan check application form to district copy for all waivers.
Embossed Original- Building Dept./Applicant Copy -, Applicant/Receipt Copy - Accounting
4 .